Med Sure (part 2)

1

A nurse is caring for clients with a variety of problems. Which health problem does the nurse determine poses the greatest risk for the development of a pulmonary embolus? 1 Atrial fibrillation 2 Forearm laceration 3 Migraine headache 4 Respiratory infection

1

An older client with shortness of breath is admitted to the hospital. The medical history reveals hypertension in the last year and a diagnosis of pneumonia three days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention? 1 Oxygen Saturation: 89% 2 Body temperature: 101°F 3 Blood Pressure: 130/80 mmHg 4 Respiratory rate: 26 beats/minute

4

The nurse provides preoperative education to a client with extensive cancer of the upper right lobe of the lung who is scheduled for a lobectomy. The nurse concludes that the teaching was effective when the client makes which statement? 1 "The healthcare provider is going to use a laser to destroy all of the cancer cells. I will have oxygen in place to help me breathe after the surgery." 2 "I don't even need the lobe they are taking out. I still have three lobes in my left lung to help me breathe after the surgery." 3 "I know that my entire right lung will be removed. I will have chest tubes to help with drainage after surgery." 4 "The remaining lung tissue will fill in the empty space. I will have chest tubes to help with drainage after surgery."

4

The registered nurse is caring for a client with dysrhythmias. Which action should the nurse perform immediately according to priority? 1 Monitoring oxygen saturation 2 Establishing intravenous access 3 Administer oxygen via nonrebreather mask 4 Ensure airway, breathing, and circulation (ABC)

2,3,5

What are the mediators of injury in IgE-mediated hypersensitivity reactions? Select all that apply. 1 Cytokines 2 Mast cells 3 Histamines 4 Neutrophils 5 Leukotrienes

2

A client is admitted to the emergency department with burns to the anterior trunk, entire right arm, and anterior right leg. The practitioner prescribes morphine sulfate for pain. What route of administration should the nurse expect to administer this medication? 1 Orally 2 Intravenously 3 Subcutaneously 4 Intramuscularly

3

Polycythemia is frequently associated with chronic obstructive pulmonary disease (COPD). Which should the nurse monitor for when assessing for this complication? 1 Pallor and cyanosis 2 Dyspnea on exertion 3 Elevated hemoglobin 4 Decreased hematocrit

2

A nurse is providing tracheostomy care. Which action is priority? 1 Place the client in the semi-Fowler position 2 Maintain sterile technique during the procedure 3 Monitor body temperature after the procedure is completed 4 Clean the inner cannula with sterile water when it is removed

2

The nurse is assessing a client with burns over 15% of the body. Which priority nursing action should be taken to ensure a complete assessment? 1 Determining the level of mobility 2 Removing the clothes of the client 3 Placing the client in recumbent position 4 Cleaning the wounds with antiseptic solution

1,2,3

The nurse is performing a skin assessment of a client. Which findings in the client may indicate a risk of skin cancer? Select all that apply. 1 Lesion 2 Lumps 3 Rashes 4 Bruising 5 Dryness

1

Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers? 1 Incontinence and inability to move independently 2 Periodic diaphoresis and occasional sliding down in bed 3 Reaction to just painful stimuli and receiving tube feedings 4 Adequate nutritional intake and spending extensive time in a wheelchair

3

A client is admitted with systemic lupus erythematosus (SLE). The laboratory report shows the presence of neutrophils and monocytes as mediators of injury. Which type of hypersensitivity reaction most likely occurred in the client? 1 Type I 2 Type II 3 Type III 4 Type IV

1,3

A client is prescribed albuterol to relieve severe asthma. What adverse effect will the nurse instruct the client to anticipate? Select all that apply. 1 Tremors 2 Lethargy 3 Palpitations 4 Visual disturbances 5 Decreased pulse rate

2

A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who develops a pneumothorax and has a chest tube inserted. Which primary purpose of the chest tube will the nurse consider when planning care? 1 Lessens the client's chest discomfort 2 Restores negative pressure in the pleural space 3 Drains accumulated fluid from the pleural cavity 4 Prevents subcutaneous emphysema in the chest wall

1,3,2,4,5

A nurse is suctioning a client's tracheostomy. Place the nursing actions in order of priority when performing this procedure 1. Don sterile gloves 2. Auscultate the lungs and check the heart rate 3. Turn suction on to between 80 and 120 mm Hg pressure 4. Guide the catheter into the tracheostomy tube using a sterile gloved hand 5. Hyperoxygenate using 100% oxygen

2

A nurse administers beclomethasone by inhalation to a client with asthma, and the client asks why this medication is necessary. What should the nurse explain is the purpose of this pharmacologic therapy? 1 Promotes comfort 2 Decreases inflammation 3 Stimulates smooth muscle relaxation 4 Reduces bacteria in the respiratory tract

2,1,3,4,5

A client has an endotracheal tube and is receiving mechanical ventilation. The nurse identifies that periodic suctioning may be necessary. The nurse follows a specific protocol when performing this procedure. Place the steps in the order that they should be performed 1. Auscultate lung sounds. 2. Obtain the vital signs. 3. Suction for approximately 10 seconds. 4. Rotate the catheter during its withdrawal 5. Hyperoxygenate for 30 seconds.

2

A client is diagnosed with hypertension that is related to atherosclerosis. Which information should the nurse consider when planning care for this client? 1 Renin causes a gradual decrease in arterial pressure. 2 Lipid plaque formation occurs within the arterial vessels. 3 Development of atheromas within the myocardium is characteristic. 4 Mobilization of free fatty acid from adipose tissue contributes to plaque formation.

3

A client is receiving furosemide to help treat heart failure. Which laboratory result will cause the nurse to notify the primary healthcare provider? 1 Hematocrit 46% 2 Hemoglobin 14.1 g/dL (141 mmol/L) 3 Potassium 3.0 mEq/L (3.0 mmol/L) 4 White blood cell 9200/mm3 (9.2 × 109/L)

1,3,5

A client suffers hypoxia and a resultant increase in deoxygenated hemoglobin in the blood. What are the best sites to assess this condition? Select all that apply. 1 Lips 2 Sclera 3 Mouth 4 Sacrum 5 Nail beds 6 Shoulders

2

A client who was recently diagnosed with emphysema develops a malignancy in the right lower lobe of the lung, and a lobectomy is performed. After surgery, the client is receiving oxygen by nasal cannula at 2 L per minute. Blood gas results demonstrate respiratory acidosis. What should be the initial nursing intervention? 1 Administer oral fluids. 2 Encourage deep breathing. 3 Increase the oxygen flow rate. 4 Perform nasotracheal suctioning

2

A client with a pulmonary embolus is intubated and placed on mechanical ventilation. What nursing action is important when suctioning the endotracheal tube? 1 Apply negative pressure while inserting the suction catheter. 2 Hyperoxygenate with 100% oxygen before and after suctioning. 3 Suction two to three times in succession to effectively clear the airway. 4 Use rapid movements of the suction catheter to loosen secretions.

3

A client complaining of fatigue is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). What should the nurse do to prevent fatigue? 1 Provide small, frequent meals 2 Encourage pursed-lip breathing 3 Schedule nursing activities to allow for rest 4 Encourage bed rest until energy level improves

2

What is the etiology of the development of pressure ulcers in an 80-year-old client? 1 Atrophy of the sweat glands 2 Decreased subcutaneous fat 3 Stiffening of the collagen fibers 4 Degeneration of the elastic fibers

2

What is the priority goal for a client with asthma who is being discharged from the hospital with prescriptions for inhaled bronchodilators? 1 Is able to obtain pulse oximeter readings 2 Demonstrates use of a metered-dose inhaler 3 Knows the healthcare provider's office hours 4 Can identify the foods that may cause wheezing

4

What should the nurse do to help alleviate the distress of a client with heart failure and pulmonary edema? 1 Encourage frequent coughing. 2 Elevate the client's lower extremities. 3 Prepare for modified postural drainage. 4 Place the client in the orthopneic position.

2

When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first? 1 Interview the client for a health history. 2 Assess the client's heart and lung sounds. 3 Monitor the client's pulse and temperature. 4 Obtain the client's blood specimen for electrolytes.

3

When assessing a client with heart failure, the nurse asks what aggravates the problem. Which activity should the nurse expect will cause the client the greatest distress? 1 Getting up from bed in the morning 2 Walking to visit the next-door neighbor 3 Climbing a flight of stairs to the bedroom 4 Leaving the table immediately after a meal

4

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? 1 Administer sedatives around the clock 2 Turn client every four hours 3 Increase ventilator settings as needed 4 Suction as needed

1,2

A client hospitalized with heat stroke presents with a body temperature of 106° F and skin that is hot and dry. Which priority interventions should be provided to the client? Select all that apply 1 Remove the client's clothing. 2 Immerse the client in cold water. 3 Keep the client from eating or drinking. 4 Transfer the client to the critical care unit. 5 Administer parenteral benzodiazepine to the client.

4

A client requiring surgery because of mitral valve incompetence is admitted to the hospital and states, "I need a new valve, with an oil change, too!" What is the nurse's most therapeutic response? 1 "You really don't need to hide your anxieties." 2 "You sure came to the right place for a valve job." 3 "I'm glad to see you're handling the situation well." 4 "I'm sure you have a great deal to ask about your surgery."

3

A client's chest tube has accidentally dislodged. What is the nursing action of highest priority? 1 Place the client in a left side-lying position. 2 Apply oxygen via nonrebreather mask. 3 Apply a petroleum gauze dressing over the site. 4 Prepare to reinsert a new chest tube.

1

A nurse is auscultating a client's heart sounds and hears S1. Which valves is the nurse assessing? 1 Mitral and tricuspid 2 Aortic and tricuspid 3 Mitral and pulmonic 4 Aortic and pulmonic

4

A nurse is caring for a client on mechanical ventilation. The nurse should monitor for which sign of hyperventilation? 1 Tetany 2 Hypercapnia 3 Metabolic acidosis 4 Respiratory alkalosis

4

A nurse is caring for a client who has been admitted with right-sided heart failure. The nurse notes that the client has dependent edema around the area of the feet and ankles. To characterize the severity of the edema, the nurse presses the medial malleolus area, noting an 8 mm depression after release. How should the edema be documented? 1. 1+ 2. 2+ 3. 3+ 4. 4+

2,3,4

A nurse is caring for a community-dwelling older adult with hypertension. What interventions should the nurse take to ensure the client's well-being? Select all that apply. 1 Suggest that the client have annual Papanicolaou (Pap) smears and mammograms 2 Promote dietary modifications by using varied techniques 3 Assess the client's current lifestyle and promote lifestyle changes 4 Monitor the client's blood pressure and weight and establish blood pressure screening programs 5 Teach the client about correct body mechanics and the availability of mechanical appliances

4

The nurse is conducting a nutrition class for a group of clients with heart failure (HF). Which information is most important for the nurse to share with the class? 1 Restricting fluid intake 2 Eating a low caloric diet to reduce weight 3 Recognizing which products are high in cholesterol 4 Choosing fresh or frozen vegetables instead of canned ones

2

The nurse is providing postoperative care to a client with lung cancer who had a partial pneumonectomy. When inspecting the client's dressing, the nurse notes puffiness of the tissue around the surgical site. When the nurse palpates the site, the tissue feels spongy, and crackles can be felt. How does the nurse describe this assessment finding? 1 Stridor 2 Crepitus 3 Pitting edema 4 Chest distention

1

A nurse is providing immediate postoperative care to a client with a tracheostomy tube in place. The client suddenly develops noisy, increased respirations and an elevated heart rate. What action should the nurse take immediately? 1 Suction the tracheostomy. 2 Change the tracheostomy tube. 3 Readjust the tracheostomy tube and tighten the ties. 4 Perform a complete respiratory assessment.

2

Which instruction would be most beneficial for an aging African-American client with hypertension? 1 "Check the pulse daily." 2 "Have an annual urinalysis." 3 "Record blood pressure weekly." 4 "Visit an ophthalmologist monthly."

2

Which intervention should the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma? 1 Apply a thoracic binder for support. 2 Encourage coughing and deep breathing. 3 Defer pain medication the first day after injury. 4 Position the client face-down on a soft mattress.

2,3,4

Which nursing interventions should the nurse provide to an older client with hypertension? Select all that apply. 1 Provide skin care 2 Advise the client to limit salt intake 3 Teach stress management 4 Instruct the client to quit smoking 5 Advise the client to eat finger foods

1 (A papule is an elevated, solid skin lesion of less than 0.5 to 1 cm in diameter. A macule is a circumscribed, flat area with a change in skin color. The vesicle is a circumscribed, superficial collection of serous fluid. A pustule is an elevated, superficial lesion filled with purulent fluid.)

While assessing the skin of a client, the nurse notices an elevated, solid lesion measuring 4 mm × 4 mm in size. Which type of lesion is observed in the client? 1 Papule 2 Vesicle 3 Pustule 4 Macule

1,2,4

While assessing the skin of a client, the nurse notices that the skin does not return to the normal position immediately after a gentle pinch. What can be appropriately attributed to this condition? Select all that apply 1 Aging 2 Cachexia 3 Liver failure 4 Dehydration 5 Sun exposure

4

While assessing the skin of an older adult, the nurse observes that the skin has a dry and uneven color. Which change is responsible for this condition? 1 Decreased subcutaneous fat 2 Decreased extracellular water 3 Decreased proliferation capacity 4 Decreased activity of sebaceous glands

2

A nurse provides smoking-cessation education to a client with chronic obstructive pulmonary disease (COPD). The nurse concludes that the client is ready to quit smoking when the client makes which statement? 1 "I'll just finish the carton that I have at home." 2 "I'll cut back to a half pack a day." 3 "I find that smoking is the only way I can relax." 4 "I should find this easy because I don't smoke when I drink."

2,3,4,5

A nurse uses the Braden Scale to predict a client's risk of developing pressure ulcers. Which data should the nurse use to determine a client's score on this scale? Select all that apply. 1 Age 2 Anorexia 3 Hemiplegia 4 History of diabetes 5 Urinary incontinence

3

An older client who has had multiple hospital admissions for recurring heart failure is returned to the hospital by an adult child. The client is admitted for observation to the coronary care unit and calmly states, "I know I'm sick, but I can really take care of myself at home." What should the nurse conclude that the client most likely is attempting to do? 1 Suppress fears 2 Deny the illness 3 Maintain independence 4 Reassure the adult child

3

How can the nurse best describe heart failure to a client? 1 A cardiac condition caused by inadequate circulating blood volume 2 An acute state in which the pulmonary circulation pressure decreases 3 An inability of the heart to pump blood in proportion to metabolic needs 4 A chronic state in which the systolic blood pressure drops below 90 mm Hg

1,2,3,4

What clinical indicators should a nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? Select all that apply 1 Crackles 2 Atelectasis 3 Hypoxemia 4 Severe dyspnea 5 Increased pulmonary wedge pressure

2,3

Which throat manifestations are the key features for a client with acute viral pharyngitis? Select all that apply 1 Petechiae on the soft palate 2 Scant or no tonsillar exudate 3 Slight erythema of the pharynx and tonsils 4 Severe hyperemia of the pharyngeal mucosa 5 Erythema of the tonsils with yellow exudates

4

Which type of allergic condition of the skin manifests in the client as delayed hypersensitivity? 1 Urticaria 2 A drug reaction 3 Atopic dermatitis 4 Allergic contact dermatitis

2

While caring for a client with asthma, the nurse auscultates a bilateral high-pitched, continuous whistling sound in the anterior lung fields. What finding does the nurse document in the medical record? 1 Crackles 2 Wheezes 3 Rhonchus 4 Pleural friction rub

3

A client sustains fractured ribs as a result of a motor vehicle collision. Which clinical indicator identified by the nurse suggests the client may be experiencing a complication of fractured ribs? 1 Report of pain when taking deep breaths 2 Client is observed splinting the fracture site 3 Diminished breath sounds on the affected side 4 Bowel sounds are auscultated in the lower chest

3

A client has a right upper lobectomy to remove a cancerous lesion. After the surgery, the nurse monitors the client for the most life-threatening complication, which is what? 1 Hemothorax caused by decreased thoracic drainage 2 Dyspnea caused by increased intrathoracic pressure 3 Decreased cardiac output because of mediastinal shift 4 Pneumothorax caused by increased abdominal pressure

4

A client is admitted to the hospital for replacement of the mitral valve. The primary purpose of the nurse checking the pulses in the client's legs frequently after surgery is detection of what? 1 Atrial fibrillation 2 Postsurgical bleeding 3 Arteriovenous shunting 4 Peripheral thrombophlebitis

3

The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. Which is the priority nursing intervention? 1 Initiate oxygen therapy 2 Obtain chest x-ray film immediately 3 Place client in a high-Fowler position 4 Assess the client for a pleural friction rub

1

Which action should be the nurse's first priority for a client with major burns? 1 Assessing airway patency 2 Checking the client from head to toe 3 Administering oxygen as needed 4 Elevating the extremities if no fractures are noticed

4

Which central nervous system manifestation observed in a client with a respiratory disorder indicates inadequate oxygenation? 1 Late cyanosis 2 Early tachypnea 3 Late use of accessory muscles 4 Early unexplained restlessness

1,2,3,4

The client is admitted with sinus tachycardia. To treat the dysrhythmia, the nurse will look for potential causes. Which causes will the nurse look for in this client? Select all that apply. 1 Anxiety 2 Caffeine 3 Exercise 4 Anemia 5 Hypothermia

3

The healthcare provider prescribes a low-fat, 2-gram sodium diet for a client with hypertension. The nurse should explain that the purpose of restricting sodium is to do what? 1 Chemically stimulate the loop of Henle 2 Diminish the thirst response of the client 3 Prevent reabsorption of water in the distal tubules 4 Cause fluid to move toward the interstitial compartment

4

The nurse assesses a client with emphysema. The nurse expects to find which sign of chronic obstructive pulmonary disease (COPD)? 1 Increased breath sounds 2 Atrophic accessory muscles 3 Shortened expiratory phase of the respiratory cycle 4 Chest with an increased anteroposterior (AP) diameter

3

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia? 1 Red blood cell count 2 Sputum culture 3 Arterial blood gas 4 Total hemoglobin

2

The nurse is caring for a client who is admitted with the diagnosis of mild heart failure. Which type of lung sounds should the nurse expect to hear? 1 Stridor 2 Crackles 3 Wheezes 4 Friction rubs

1

What is an example of a type I hypersensitivity reaction? 1 Anaphylaxis 2 Serum sickness 3 Contact dermatitis 4 Blood transfusion reaction

4

The registered nurse is preparing to perform a physical assessment of a client with darker skin who is suspected to have jaundice. Which statement by the nurse indicates effective technique? 1 "I will examine the conjunctiva." 2 "I will examine the lips and tongue." 3 "I will examine the nail beds, palms, and soles." 4 "I will examine the sclera closest to the iris."

2

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus? 1 Limit the client's fluid intake. 2 Teach the client how to exercise the legs. 3 Encourage use of the incentive spirometer. 4 Maintain the knee gatch position at an angle.

1

A nurse is caring for a client who has chest tubes inserted to treat a hemothorax that resulted from a crushing chest injury. While planning care for a stationary chest tube drainage system, which purpose of the first chamber will the nurse consider? 1 Collect drainage 2 Ensure adequate suction 3 Maintain negative pressure 4 Sustain a continuance of the water seal

1,2

A nurse is caring for a client who sustained skin injuries 3 days ago. Which changes can be noticed by the nurse in the client? Select all that apply 1 Local edema 2 Erythema 3 Pale color of scar tissue 4 Formation of scar tissue 5 Red colored granulation tissue

2

A nurse is caring for a client who was admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease and is receiving oxygen at 2 L/min via nasal cannula. What is the primary focus of therapy when caring for this client? 1 Limiting hydration 2 Improving ventilation 3 Decreasing exogenous oxygen 4 Correcting the bicarbonate deficit

1,2,4

A nurse is caring for a client with a diagnosis of right ventricular heart failure. The nurse expects what assessment findings associated with right-sided heart failure? Select all that apply. 1 Dependent edema 2 Swollen hands and fingers 3 Collapsed neck veins 4 Right upper quadrant discomfort 5 Oliguria

1

A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which clinical finding supports the nurse's suspicion that the client is developing cor pulmonale? 1 Peripheral edema 2 Productive coughing 3 Twitching of the extremities 4 Lethargy progressing to coma

1

A client with chronic bronchitis smokes one or two cigarettes a day and has not been performing the prescribed pulmonary physiotherapy exercises because they are too tiring. Which is the best response by the nurse? 1 "Tell me about your typical day before the exercises were prescribed." 2 "Smoking is probably the cause of the severity of your disease at this time." 3 "I can't make you stop doing what you are doing, and it's your choice to be sick or well." 4 "Your being so sick is probably because of your smoking and your choosing not to exercise."

3

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and PCO2 of 60. These blood gases require nursing attention because they indicate which condition? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

3

A client with cystic fibrosis asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to do what? 1 Relieve bronchial spasms 2 Increase depth of respirations 3 Loosen pulmonary secretions 4 Expel carbon dioxide from the lungs

3

A client with emphysema is admitted to the hospital with pneumonia. On the third hospital day, the client complains of a sharp pain on the right side of the chest. The nurse suspects a pneumothorax. What breath sound is most likely to be present when the nurse assesses the client's right side? 1 Crackling 2 Wheezing 3 Decreased sounds 4 Adventitious sounds

4

A client with heart failure is to receive digoxin and asks the nurse why the medication is necessary. What physiologic response will the nurse include when answering the client's question? 1 Reduces edema 2 Increases cardiac conduction 3 Increases rate of ventricular contractions 4 Slows and strengthens cardiac contractions

4

A client with small-cell lung cancer is receiving chemotherapy. A complete blood count is prescribed before each round of chemotherapy. Which component of the complete blood count is of greatest concern to the nurse? 1 Platelets 2 Hematocrit 3 Red blood cells (RBCs) 4 White blood cells (WBCs)

2

A nurse is monitoring a client admitted with a diagnosis of myocardial infarction (MI) for dysrhythmias. Which reason for increased incidence of dysrhythmias in this client should the nurse monitor? 1 Metabolic alkalosis 2 Myocardial hypoxia 3 Decreased catecholamine secretion 4 Increased parasympathetic nervous system stimulation

4

A client with a dysrhythmia is admitted to telemetry for observation. In the morning the client asks for a cup of coffee. What is the nurse's best response? 1 "Hot drinks such as coffee are not good for your heart." 2 "Coffee is not permitted on the diet that was prescribed for you." 3 "You cannot have coffee. I can bring you a cup of tea if you like." 4 "Coffee has caffeine that can affect your heart. It should be avoided."

4

A client with a history of emphysema is admitted with a diagnosis of acute respiratory failure with respiratory acidosis. Oxygen is being administered at 3 L/min nasal cannula. Four hours after admission, the client has increased restlessness and confusion followed by a decreased respiratory rate and lethargy. What should the nurse do? 1 Question the client about the confusion. 2 Change the method of oxygen delivery. 3 Percuss and vibrate the client's chest wall. 4 Discontinue or decrease the oxygen flow rate.

1,5

A client with a history of heart failure admits to the nurse that a salt-restricted diet has not been followed. The client reports increased ankle swelling and shortness of breath that is relieved by sitting up. For which other clinical indicators of fluid retention should the nurse monitor the client? Select all that apply 1 Headache 2 Thready pulse 3 Decreased blood pressure 4 Dizziness when standing up 5 Crackles on lung auscultation

4

A nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. On what aspect of care should the nurse focus? 1 Teaching how to make a room allergy-free 2 Referring to a support group for individuals with asthma 3 Arranging with the college to ensure a speedy return to classes 4 Evaluating whether the necessary lifestyle changes are understood

3

A client with asthma is being taught how to use a peak flow meter to monitor how well the asthma is being controlled. What should the nurse instruct the client to do? 1 Perform the procedure once in the morning and once at night. 2 Move the trunk to an upright position and then exhale while bending over. 3 Inhale completely and then blow out as hard and as fast as possible through the mouthpiece. 4 Place the mouthpiece between the lips and in front of the teeth before starting the procedure.

3

A client with burns is hospitalized in the emergency department and advised to get an electrocardiogram (ECG) done. Which type of burn injury has the client most likely sustained? 1 Flame burn 2 Chemical burn 3 Electrical burn 4 Radiation burn

3,4,5

A 50-year-old client with a 30-year history of smoking reports a chronic cough and shortness of breath related to chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 100, a blood pressure of 138/82, a respiratory rate of 32, a tympanic temperature 36.8 °C, and an oxygen saturation of 80%. Which vital signs obtained by the nurse during the therapy indicates a positive outcome? Select all that apply 1 Radial pulse: 70 2 Temperature: 37 °C 3 Respiratory rate: 14 4 Blood pressure: 110/70 5 Oxygen saturation: 92%

3

A client develops epistaxis and seeks treatment at a first aid station. Which action should the nurse take? 1 Tilt the head backward 2 Pack the nose with tissue 3 Apply direct lateral pressure to the nose 4 Instruct the client to blow the nose gently

1

A client develops subcutaneous emphysema after the surgical creation of a tracheostomy. What assessment by the nurse most readily detects this complication? 1 Palpating the neck or face 2 Evaluating the blood gases 3 Auscultating the lung fields 4 Reviewing the chest x-ray film

1

A client diagnosed with asthma has received a prescription for an inhaler. The nurse teaches the client how to determine when the inhaler is empty, instructing the client to do what? 1 Count the number of doses taken. 2 Taste the medication when sprayed into the air. 3 Shake the canister. 4 Place the canister in water to see if it floats.

22.5

A client is admitted for treatment of partial- and full-thickness burns of the entire right lower leg extremity and the anterior portion of the right upper arm. A nurse performs an immediate appraisal of the percentage of body surface area burned using the rule of nines. What percentage of body surface area does the nurse determine is affected? Record the answer to one decimal place. _______%

2

A client is admitted to the hospital with a diagnosis of heart failure and acute pulmonary edema. The healthcare provider prescribes furosemide 40 mg intravenous (IV) stat to be repeated in 1 hour. What nursing action will best evaluate the effectiveness of the furosemide in managing the client's condition? 1 Perform daily weights 2 Auscultate breath sounds 3 Monitor intake and output 4 Assess for dependent edema

4,2,1,3

A client is admitted to the hospital with a tentative diagnosis of pneumonia. The client has a high fever and is short of breath. Bed rest, oxygen via nasal cannula, an intravenous antibiotic, and blood and sputum specimens for culture and sensitivity (C & S) are prescribed. Place these interventions in the order in which they should be implemented. 1. Specimens for C & S 2. Bed rest 3. Administration of an antibiotic 4. Oxygen via nasal cannula

4

A client is being treated for pressure ulcers. The primary healthcare provider advises the client to eat foods with high amounts of vitamin C. What is the role of vitamin C in wound healing? 1 Vitamin C aids in the process of epithelialization. 2 Vitamin C helps in the synthesis of immune factors. 3 Vitamin C increases the metabolic energy required for inflammation. 4 Vitamin C is required for collagen production by fibroblasts.

1,2,3,4,6,5

A client is severely injured with burns and sustained major trauma from a fire incident. What is the order of assessments according to priority in this situation? 1. Monitoring systolic blood pressure 2. Assessing the score of eye-opening 3. Removing the clothing with scissors 4. Palpating for the presence of a radial pulse 5. Providing bag-valve-mask (BVM) ventilation 6. Using a jaw-thrust maneuver to establish an airway

1,2

A client sustains a crushing injury to the lower left leg, and a below-the-knee amputation is performed. For which common clinical manifestations of a pulmonary embolus should the nurse assess this client? Select all that apply. 1 Sharp chest pain 2 Acute onset of dyspnea 3 Pain in the residual limb 4 Absence of the popliteal pulse 5 Blanching of the affected extremity

2

A client who develops heart failure has a serum potassium level of 2.3 mEq/L (2.3 mmol/L). Digoxin and potassium chloride are prescribed. What action should the nurse take? 1 Double the dose of potassium chloride and administer it with the prescribed digoxin. 2 Hold the dose of digoxin, administer the potassium chloride, and call the primary healthcare provider immediately. 3 Give the digoxin and potassium chloride as prescribed and report the laboratory results to the primary healthcare provider. 4 Administer the prescribed digoxin and potassium chloride with a glass of orange juice and continue to monitor the client.

3

A client who is receiving a screening test for tuberculosis (TB) asks the nurse what a positive reaction will mean. What should the nurse explain that a positive reaction indicates? 1 A depressed immune system 2 An active tuberculosis infection 3 A previous exposure to the organism 4 An imminent tuberculosis infection

3

A client with a coronary occlusion is experiencing chest pain and distress. Why does the nurse administer oxygen? 1 To prevent dyspnea 2 To prevent cyanosis 3 To increase oxygen concentration to heart cells 4 To increase oxygen tension in the circulating blood

3

A nurse is advising a client about the risks associated with failing to seek treatment for acute pharyngitis caused by beta-hemolytic streptococcus. For what health problem is the client at risk? 1 Asthma 2 Anemia 3 Endocarditis 4 Reye syndrome

4

A nurse is providing immediate postoperative care to a client who had a lung resection for a malignancy. The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse? 1 A column of water 20 cm high in the suction control chamber 2 75 mL of bright red blood in the drainage collection chamber 3 An intact occlusive dressing at the insertion site 4 Constant bubbling in the water seal chamber

3

After surgery a client develops a deep vein thrombosis and a pulmonary embolus. Heparin via a continuous drip is prescribed. Several hours later, vancomycin intravenously every 12 hours is prescribed. The client has one intravenous (IV) site: a peripheral line in the left forearm. What action should the nurse take? 1 Stop the heparin, flush the line, and administer the vancomycin. 2 Use a piggyback setup to administer the vancomycin into the heparin. 3 Start another IV line for the vancomycin and continue the heparin as prescribed. 4 Hold the vancomycin and tell the healthcare provider that the drug is incompatible with heparin.

1

After surgery, a client reports sudden severe chest pain and begins coughing. The nurse suspects the client has a thromboembolism. What characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus? 1 Pink 2 Clear 3 Green 4 Yellow

25

Levofloxacin 750 mg intravenous piggyback (IVPB) is prescribed for a client with pneumonia. The dose is available in 150 mL of 5% dextrose and is to infuse over 90 minutes. The administration set has a drop factor of 15 drops per mL. At how many drops per minute should the nurse regulate the IVPB to infuse? Record your answer using a whole number. ___ gtt/minute

3

The nurse instructed a client with asthma about the use of a peak flow meter at home. The client assesses the peak expiratory flow by using the peak flow meter. Which action performed by the client would be appropriate when the reading is in the yellow zone? 1 Perform the peak expiratory flow again immediately 2 Increase the prescribed drug therapy 3 Use a prescribed reliever drug therapy 4 Reassess the asthma plan and change the controller medication

3

The nurse is caring for a client who had a wedge resection of a lobe of the lung and now has a chest tube with a three-chamber underwater drainage system in place. Which main purpose of the third chamber of the underwater drainage system should the nurse consider when planning care? 1 Acts as a drainage container 2 Provides an airtight water seal 3 Controls the amount of suction 4 Allows for escape of air bubbles

2,3,4

The nurse is caring for a client with tuberculosis. Which suggestions from the nurse will be beneficial for the client? Select all that apply. 1 "Take the daily dose during daytime." 2 "Avoid exposure to any inhalation irritants." 3 "Eat foods that are rich in protein, vitamins C and B." 4 "Cover the mouth and nose with a tissue when coughing or sneezing." 5 "Avoid sputum specimens for 2 to 4 weeks once drug therapy is initiated."

3

The nurse is interpreting responses to tuberculin skin testing in a 58-year-old client with end-stage kidney disease secondary to diabetes mellitus. Which finding would indicate a positive reaction? 1 Presence of acid-fast bacilli in the sputum 2 A 6-mm area of induration at the test's injection site 3 An 11-mm area of induration at the test's injection site 4 Presence of reddened, flat areas at the test's injection site

2,3,5

The nurse is planning to teach a client with heart failure about the signs and symptoms of cardiac decompensation. What clinical manifestations should the nurse include? Select all that apply 1 Weight loss 2 Extreme fatigue 3 Coughing at night 4 Excessive urination 5 Difficulty breathing

4

The nurse teaches a client about cleaning the skin to prevent pressure ulcers. Which statement made by the client indicates the nurse needs to follow up? 1 "I should gently pat the skin." 2 "I should use mild, heavily fatted soap." 3 "I should wash with tepid rather than hot water." 4 "I should apply powders or talc on a perineum wound."

1,2,4

The registered nurse is teaching a nursing student about interventions that reduce the risk of pressure ulcers in a client. Which statements made by the nursing student indicate effective learning? Select all that apply 1 "I will elevate the head of the client's bed to no more than 30 degrees." 2 "I will ensure that the client is turned and repositioned at least every two hours." 3 "I will advise the client to apply talc directly to the perineum." 4 "I will ensure that the client's fluid intake is 2000 to 3000 mL/day." 5 "I will teach the client to refrain from eating a high-protein and calorie diet."

4

Which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client? 1 Serum sodium of 139 mEq/L (139 mmol/L) 2 Serum chloride of 100 mEq/L (100 mmol/L) 3 Serum calcium of 10.2 mg/dL (2.55 mmol/L) 4 Serum potassium of 7.2 mEq/L (7.2 mmol/L)

4 (Serum sickness is a type III immune complex-mediated reaction. A delayed reaction is a type IV hypersensitivity reaction that may include poison ivy skin rashes, graft rejection, and sarcoidosis. A cytotoxic reaction is a type II hypersensitivity reaction that includes autoimmune hemolytic anemia, Goodpasture syndrome, and myasthenia gravis. An immediate reaction is a type I hypersensitive reaction that includes allergic asthma, hay fever, and anaphylaxis.)

Which type of hypersensitivity reaction is present in a client with a body temperature of 102 °F, severe joint pain, rashes on the extremities, and enlarged lymph nodes from serum sickness? 1 Delayed reaction 2 Cytotoxic reaction 3 Immediate reaction 4 Immune complex-mediated reaction